Patient safety : evaluation of the impact of nursing hours per patient day staffing method in Western Australia

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In March 2002 Western Australia (WA) mandated a new staffing method—nursing hours per patient day (NHPPD). This method used a “bottom up” approach to classify each hospital ward into one of seven categories using characteristics such as patient complexity, intervention levels, the presence of high dependency beds, the emergency/elective patient mix and patient turnover. Once classified, NHPPD were prescribed for each ward. The purpose of this study was two-fold focusing on data from three adult tertiary hospitals (four of seven ward categories: A, B, C and D combined), and individual ward categories A, B, C and D at one adult tertiary hospital. The first purpose was to determine the impact of implementing this staffing method (NHPPD) on nursing-sensitive outcomes (NSOs). The second was to determine the relationship between skill mix and NSOs following implementation of NHPPD. The research design was an interrupted time series and used retrospective analysis of administrative data. Patient and staffing data using the NHPPD method over a four year period were analysed. The 14 NSOs were central nervous system (CNS) complications, wound infections, pulmonary failure, urinary tract infection, pressure ulcer, pneumonia, deep vein thrombosis, ulcer, gastritis and upper gastrointestinal bleed, sepsis, physiologic/metabolic derangement, shock/cardiac arrest, mortality, failure to rescue and length of stay. The study found significant decreases in the rates of nine NSOs when examining hospital-level data following implementation of NHPPD (including mortality, sepsis and pneumonia). At the ward level, significant decreases in the rates of five NSOs (including mortality, shock/cardiac arrest and UTIs) occurred. Significant decreases in rates of eight NSOs (including failure to rescue, mortality and pneumonia) occurred with each 1% increase in RN hours across the three hospitals. At ward category level, significant decreases in the rates of five NSOs occurred with every 1% increase in RN hours (including failure to rescue, DVT and pneumonia). The findings of this study suggest a richer skill mix, even with relatively small changes (1%), continues to benefit patients by improving NSOs. This study also provides nurse leaders with evidence to support the continuation of the NHPPD staffing method. It also adds to evidence about the importance of nurse staffing to patient safety, evidence that must influence policy. Moreover, this study is one of the first to empirically review a specific nurse staffing method, based on an individual assessment of each ward to determine staffing requirements, rather than a “one-size-fits-all” approach.
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